Wednesday, August 4, 2010

Dave showed up at my office last week with neck pain, worsening weakness in his arms and legs, and changes in his bladder control. All signs pointed to something gone bad in his neck.

His internist had already thought of this, because he'd ordered the appropriate MRI's. And they'd all been read as normal, leaving me without a cause.

Here is where the problem began. EVERYTHING about Dave's exam and story pointed to something serious in his neck. But the tests were normal...

There are A LOT of MRI places out there. Some of them have good quality machines, while others haven't updated their machines, or software, in a long time. In addition to this, some places use specially trained neuro-radiologists to read MRI's, while others use general radiologists. So there's a different quality of reader, too.

This isn't meant as a slap against general radiologists. As a general neurologist, I don't claim to be exceptionally good at various subdivisions of my field, either. No one is good at everything, and recognizing our limitations is part of the job.

As a result, Annie and I have a short list of MRI places I use, where I trust both the equipment and radiologists.

But your average internist doesn't usually know the difference, as they're too busy with the insanity of a general medical practice. Most of the time the decision is made by a scheduling person, based on the patient's insurance, when the next available opening is, and maybe even what place brought them lunch. And, Dave, unfortunately, had his studies done at Shitty MRI, Inc.

So I called Shitty MRI, Inc., and asked for the films, which came the next day. The image quality was terrible, and Dave moved during the study. From what I could see, the films were unreadable.

But I'm not much of a radiologist, let alone a neuro-radiologist. So I dragged the films to someone I trust. She agreed. They were unreadable and worthless.

Now, it might have been a tolerable situation if the reading doctor had dictated something about the films being useless, and recommended they be repeated with sedation, or on a different machine, or whatever. But instead he dictated them as normal.

So I needed another MRI, done on a decent machine, with sedation, and read by a neuro-radiologist. Easier said than done.

I ordered the study. His insurance denied it, on the grounds that he just had an MRI last week, and so they wouldn't pay for another.

I appealed it, and personally called their physician-reviewer. I told him the patient had something serious going wrong in his neck. I told him the previous films were worthless. I even offered to send him the films to look at himself.

He told me that I'd have to live with them, and it wasn't his fault that the ordering doctor had chosen that facility.

I admitted Dave to the hospital. It was a gamble. Once I had him in I could do whatever tests I wanted, but if I were wrong, it would be a nightmare to justify the admit to his insurance.

While I was working at my desk, Dave was rolling into the hospital's MRI. Within an hour the neuro-radiologist called me. Dave had a HUGE herniated disk in his neck, crushing his spinal cord. I called a neurosurgeon immediately, and 2 hours later Dave was having the disk, and it's threat of landing him in a wheelchair, taken out.

Dave did fine.

But the case is still pretty damn scary when you think about what might have been.

56 comments:

Good for you for being Dave's advocate. We are fighting our insurance company as we speak as my husband has been denied a round of Rituxan. Thankfully, his doctor is his advocate and we have gone from "denied" to "pending" status.

I am so sick of insurance companies calling the shots and I don't see that the current "reform" on the books is changing anything.

What do we do? What is the answer? How do we put the power of decision making back in the patients and physicians hands?

Go Grumpy!Now if I could just get my husband's insurance company to stop denying the type of Keppra he takes. Hello, Mr. Desk-Driving Insurance Lacky- it is an Anti-Seizure medicine. This type works best of all the rest- and he's tried them all. He has to make a living and support a family, which he cannot do without appropriate meds. So pay for the damn meds his doctor prescribed. Stupid United Healthcare. I wonder if that hospital trick would work for meds... hmmm...

At least we can take comfort in the fact that the insurance company is going to get stuck with a much bigger bill now. Hopefully they won't try to F Dave again in the process of trying to avoid paying it.

{{Shudder}}. I'm for the staples. Or maybe you could nail them to the front door of the headquarters of the insurance company in question, like unto Luther. It might not make them give a shit, but it would be odd enough to make them notice. And if the front door is glass, all the better.

The whole system is pretty scary. The patients don't know the costs, or much else of what's going on behind the scenes, so they can't help, the insurance companies are only motivated by profit, so they won't help, the employers paying for healthcare just want to save money, and really aren't allowed to get into the details, so they won't help, so it all falls on the doctor to be an advocate. Unfortunately, doctors don't get paid for that either, so they have to choose between what is right for their patient, and what is right for their practice. Glad to know you're one of the good guys, Grumpy.

This is why I read your blog; not only are you funny as all get out, but you're a fantastic physician, too. If I'm ever in your neck of the woods and in need of a neurologist, I'm coming to see you - I have that much faith in you as a physician.

Perhaps you should send copies of both scan to the medical board in your state. The doctor is endangering his patients using old equipment with incorrect reading of the crummy scans. It would appear to me that boarders on malpractice. (ethical insurance issue aside) You don't seem like the kinda doc that hides others mistakes to protect their shitty work.

C said is right: Dave should report the facility to the state board and his insurance company. If his complaint means the insurance company in the future will deny claims from that facility, he has done a lot of good for a lot of people.

Insurance bureaucracy is a bear, but going self-pay as a patient is not a financial option for most of us either. And there are facilities (as previously described in this blog) who take advantage of the insurance companies and there are patients who take advantage as well.

Can you suggest to the insurance company that they deny payment to Shitty MRI inc for the poor service? I mean, they paid for a service that was not provided. It might be incentive for Shitty MRI to clean up their act.

Btw, I do understand that the insurance companies need to look out for their own interests, and protect from fraud. But it seems more and more these days they are getting in between the physician and his patient. Some of their decisions seem as if they are practicing medicine themselves.

I'm lucky in that I have excellent doctors who are very particular as to which specialists and facilities they send patients to. One of my co-workers wasn't so lucky and has had nothing but problems. Good for you for being so effective in taking care of your patient!

After fighting with my insurance company recently, I just want to say:

Thanks for giving a shit. I could probably say that better, but really, it boils down to: you saw something going wrong and you did something about it. THANK YOU for giving a shit about doing the right thing.

Well, when something like this happens, I think "I sure hope they sue the doctor who said it was normal."

I know that's probably anathema on a medical board. but really: If the scans were UNREADABLE, then the doctor had the obligation to have them redone. At the least, he had the obligation to say "I can't read these."

but when you say "normal!" then you run the risk that some poor sot will avoid getting care because he thinks that the doctor actually had grounds to make a "normal" finding.

One option is for the patient to pay cash for a second MRI, and then submit that to the insurance carrier after surgery.

Prices for MRI have a VERY wide band. Cash price at the best (free standing) MRI center here is about $800. Fee at hospital is about $1400.

For over 350 pounds or so, the patient is stuck (Ha!) with the hospital, as they have the only open MRI in area.

Advanced Imaging of all kinds is a touchy subject. The technician, the machine and the software used all contribute to uncertainties. This can be worsened with the common practice of such images being read by distant radiologist. That radiologist may have difficulties with the subtle differences generated by different systems/software.

The rest of the world lives in fear that our governments will promote a US-style health system in our countries!

This whole situation is so foreign to us. Here, (in a democratic system btw) the government supplies public healthcare, funded through our taxes. MRI's aren't ordered willy-nilly but neither (to my knowledge) would this situation arise. We have a choice to have private insurance and the companies are tightly regulated by the government. And, by the way, all doctors, especially specialists are still paid much more than everyone else - enough to live in expensive houses and drive expensive cars.

Ours is not a perfect system, mistakes are still made, but at least I know that if I have a herniated disc in my neck, or an accident or illness, I will be looked after without losing my house or my family suffering. At the risk of unleashing a stream of patriotic vitriol in defense of this screwed-up system - why do American's fight fixing this? It's one of the most perplexing questions for outsiders.

Still, good on you Dr Grumpy for doing what you can under these circumstances.

Sad thing on top of it, if Dave is anything like the rest of us is that he probably pays around 7000 dollars a year in premiums for that type of sub par service, not to mention any co-pays that come after the monthly fees.

My family has insurance and we can't afford to use it, we surely can't afford to use it when you get incompetent care.~R

Very scary indeed! Shameful! WouldDave have recourse in the event thatthe insurance company gets pissy about paying ? They did just, thank God, almost paralyzed him or worse just to save the almighty buck!Great to hear he is fine. Bravo toyou for sticking with him!

This and the linked post about excessive bureaucracy in the medical system are just more proof that you must be one kick-ass awesome doctor. I see that same insanity from another angle every day as an outpatient coder, and many times wish I'd had the opportunity to attempt med school. (I wanted to help patients, not make them crazy!) But enough about me...and heaps of admiration for you for doing the right thing by your patients even in the face of inane, crazy, time-consuming bureaucracy that seems to take a lot of the "care" out of health care.

nice pickup, dr g. i recently had a preop patient with a fairly recent rind. extensive workup above the clavicles. i got the missing cardiac echo and found an asd. i'm not a neuro or vascular doc, so i'm still preening a bit over that one. residency pays off once again.

I don't know where you are, and I've never been to a neurologist, but if I ever need to to see a neurologist, I want it to be you!

Sometimes people can just be stupid. I remember back in 1985, my grandma was dying. She was in a coma, and had been for a few days. Someone at the hospital brought her some food and I thought, what the hell, I'll eat it. So I did. Someone marked on her chart that she had eaten her entire lunch. Oh brother.

"But the case is still pretty damn scary when you think about what might have been."

I'm glad it was okay for both of you. Damn, but you did well. My partner, who's an anaesthetist and sometimes does ER, says that one part of the job is to take risks and take responsibility, even when it's a grey zone law-wise. That's what comes with the title. (It also reminds me of Spiderman's "with great power comes great responsibility". Sad that the insurance companies are asses.)

This patient is either very lucky or very smart to have hired you. But a couple of thoughts that ran through my mind:Out of the 47 comments here only one (anonymous) mentions there could be assistance gained from going through the employee’s HR process. This means the patient, the consumer would need to take charge. Of the millions and millions of employee health plans out there, the majority are self-funded plans—in which the insurance carrier is used just for its network of providers and/or its administrative services (I know you know this but so, so many people do not). Remember the case a couple years ago of the college woman in Calif who needed an organ transplant but CIGNA wouldn’t do it? The plan was self-insured and the employer could have decided to cover it in a heartbeat and yet the insurance carrier took the heat and never named the employer.If this patient’s group health plan was self-insured there would be a detailed appeals process to get this under so many people’s radar since the employer pays the claims not the insurance company…..not to mention an HR person and attorney involved to alert the provider network, the broker, the consultant, the VP, etc. Or perhaps his group health plan was fully insured. In which there are still the appeals processes. It is horrible to have been told what you were told about the patient having to live with it. There is a bad rap out there of docs who are financially invested and/or refer MRIs when perhaps not necessary. You say “So I was stuck. And Dave was getting worse. What could I do? I had only one option.”The patient had the option of knowing what the provider network cost would be for the MRI vs. a hospital stay with a potential deductible and coinsurance, unless already met this earlier in the year). Maybe this benefits cost discussion did take place with the patient, as well as the knowledge of how to appeal if the employer is the one paying the claims.

Ah insurance companies! I remember well calling mine up all the time to inform them that gee whiz just because I wasn't 60 didn't mean that I didn't have osteoarthritis. Then I would go on the inform them that it was a lot cheaper to pay for drug X which I was not allergic to than to pay for the results which would occur if I were give oh gee ibuprofen.

I've told them every single time I've had a bad doctor. No check for Lithium levels when your patient has had vomiting & diarrhea? ::head:desk:: That's just one example. You have to be proactive. It's hard sometimes, especially when it's for yourself.

But I've found that the easiest way to get insurance to do things is to point out the bottom line. Therapy/test/drug X will cost less than therapy/drug/surgery Y. muahahahahahaha! Was that my out-loud type again?

Your a great doc, Dr. Grumpy!! I'm a 4th year med student (hope to go into family practice), and I would glady refer my future patients to you :)Despite the crazy patients you have to put up with; I can tell you genuinely care about them!!

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This blog is entirely for entertainment purposes. All posts about patients may be fictional, or be my experience, or were submitted by a reader, or any combination of the above. Factual statements may or may not be accurate.

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